RN Coordinator Utilization Management

Network Health; Menasha (WI); Hybrid; USD 65,000 - 85,000; Full time

Job summary

Network Health in Menasha is seeking an RN Coordinator for Utilization Management responsible for evaluating authorization requests and determining medical necessity. The ideal candidate must hold a current Wisconsin RN license and have at least four years of clinical experience.

This role requires strong communication skills and knowledge of utilization management. The position is full-time with a work schedule of 40 hours per week, Monday through Friday, and involves occasional travel to the corporate office during training.

Qualifications

• Bachelor of Science in Nursing is preferred.
• Current registered nurse licensure in Wisconsin is required.
• Minimum of four years of clinical health care experience as a Registered Nurse is essential.

Responsibilities

• Evaluate and process prior authorization requests.
• Provide education regarding utilization management activities.
• Collaborate with other departments to improve operational processes.

Skills

Clinical assessment skills

Utilization management knowledge

Communication skills

Knowledge of insurance processes

Education

Bachelor of Science in Nursing

Associate Degree in Nursing

Job description

The RN Coordinator – Utilization Management is responsible for reviewing submitted authorization requests for medical necessity, appropriateness of care, and benefit eligibility. The role evaluates applicable payment and coverage guidelines and makes determinations for authorization and payment.

Location: Candidates must reside in the state of Wisconsin for consideration. This position may be performed from a home office provided a reliable internet connection is available. Occasional travel to the Menasha corporate office is required, including the first day. In‑person training at the Menasha location is required for the first 6–8 weeks.

Hours: 1.0 FTE, 40 hours per week, 8:00 am – 5:00 pm Monday through Friday.

Job Responsibilities

• Evaluate and process prior authorization requests and referrals submitted from contracted and non‑contracted providers.
• Follow Network Health process, policies, and procedures in authorization review for all membership on a pre‑service, concurrent, and post‑service basis; verify eligibility and benefits and document all utilization management communication.
• Provide education regarding utilization management activities and processes to members, caregivers, providers, and their administrative staff.
• Participate in Utilization Management auditing, including inter‑reviewer reliability and denial file reviews.
• Refer members with complex health problems and needs to Network Health Case Management to reduce medical costs while improving quality of life and enabling self‑management of disease; conduct holistic care management assessments.
• Collaborate with other Network Health departments to develop interdepartmental operational processes.
• Support Utilization Management department programs and goals through active participation.
• Identify and screen candidates for Case Management intervention and determine appropriate level of care based on Utilization Management criteria.
• Complete assessments and plans of care, including medication regimes, treatment plans, provider follow‑up appointments, red‑flag knowledge, disease management, advance directives, life planning, and self‑management of illness to the best of member ability.
• Evaluate cases for cost savings and quality improvement potential.
• Perform other duties and responsibilities as assigned.

Job Requirements

• Bachelor of Science in Nursing, preferred.
• Associate Degree in Nursing, required.
• Current registered nurse licensure in Wisconsin, required.
• Minimum of four (4) years of clinical health care experience as a Registered Nurse (RN), required.
• Experience in insurance, managed care, and utilization management, preferred.

Network Health is an Equal Opportunity Employer. This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.